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Autoimmune hematologic diseases associated with infraclinical systemic lupus erythematosus in four patients
Autoimmune Hematologic Diseases Associated with Infraclinical Systemic Lupus Erythematosus in Four Patients A Human Equivalent of the NZB Mice
HERVB FAVRE. M.D. FRANCOIS CHATELANAT, M.D. PETER A. MIESCHER, M.D. Gtineva, Switzerlund
In four patients with a diagnosis of autoimmune hemolytic anemia or idiopathic thrombocytopenic purpura antinuclear antibodies and circulating immune complexes (Clq-BA test) have developed at some time in their history. Renal biopsy material was assayed with different methods. Immunofluorescence studies revealed granular deposits of immunoglobulin G (IgG), immunoglobulin M (IgM) and third component of complement (C3). Upon optic microscopy, three patients had mild mesangial proliferation, one a focal glomerulonephritis. Upon electron microscopy, all patients exhibited mesangial and/or subendothelial deposits. The patients have been followed for 18 to 37 years since the beginning of their disease. There has been no clinical evidence of systemic lupus erythematosus (SLE), although they present in their glomeruli immunologic and anatomic features compatible with this disease. These patients seem to be a human equivalent of the black NZB mouse which presents immunohematologic disorders and some biologic markers of SLE without having a full clinical picture of SLE. In human subjects, studies on twins [l], and findings of autoimmune markers in the families of patients with SLE [Z], provide evidence for genetic influences in the development of this disease. Furthermore, studies on NZB and NZW mice have contributed to the understanding of the genetics underlying the animal equivalent of human SLE, the NZB/NZW female hybrids showing a high incidence of murine SLE [3]. The incidence of autoimmune hemolvtic anemia with antinuclear antibodies and minimal kidney changesis high in NZB mice, but the full picture of SLE does not develop [4]. In this report we deal with four patients in whom clinical, biologic and immunologic data are similar to those observed in NZB mice. In view of the presence of circulating immune complexes and antibodies to DNA, kidney biopsies were performed in all patients iti order to immunochemically and ultrastructurally evaluate kidney pathology.
CASE REPORTS From the Departments of Medicine and Pathology, HBpital Cantonal. Geneva, Switzerland. This work has been supported by the Dinu-LiPatti Dubois-FcrriEre Foundation and the Montus Foundation. Requests for reprints should be addressed to Dr. H. Favrc, Division de Ncphrologic, HBpital Cantonal. 1211 Geneva 4 Switzerland. Manuscript accepted August 18. 1978.
Case I. The clinical history of this 63 year old woman began at the age of 48 when she complained of vaginal bleeding. The diagnosis of idiopathic thrombocytopenic purpura was made. Splenectomy was performed six months later without any change in the platelet count. She was seen for the first time by us in 1970. At that time, the physical examination was unrevealing. In summary, the laboratory findings showed a platelet count of 20,OOWmms. She was given prednisone and’Imuran@; with this medication, platelets returned to values around 100,0Wmms. In December 1974. she was hospitalized in
January 1979
The American Journal of Medicine
Volume 66
91
AUTOIMMUNE
TABLE I
HEMATOLOGIC
ET AL
Summary of Immunologic Laboratory Data Coombs’
Case No.
DISEASES AND INFRACLINICAL SLE-FAVRE
Sex
Test
F M M M
3+ 1+ 2+ 3+
I II Ill IV
Circulating
LE Ceils + -
ANF
(?,
•l+ + +
7 22 20 26
-
Normal values
a.7 f 3.1
C&O
Anticoagulant Clq-BA 67 33.2 31 44
+
13.7 f 5.6
-
20 14 16 36
+
7% 2.5
(%I 56 66 37 56 IOOf 25
Clq
(%I 120 100 98 72
77 100 90 40
IOOf 46
IOOf 32
36 72 36 20 IOOf 52
160 100 38 76 100f 36
NOTE: + = present, - = absent. ANF = The antinuclear factor was determined by immunofluorescence on human white blood cell nuclei. DS and S S = Double-stranded and single-stranded anti-DNA antibodies measured according to lzui et al. [ 121. Clq-BA = immune complexes were detected according to the method of Zubler et al. [ 131. CHso was estimated by the method described by Nydegger et al. [ 141, and the complement components Clq, C3, C4, B, by the method described by Perrin et al. [ 151.
emergency for fever and icterus which were found to be the consequence of a hemolytic crisis. The patient was pale and icteric. The remainder of the examination was within normal limits. On admission, the hematocrit value was 16 per cent, hemoglobin level 4.4 g/100 ml, red cells 1,300,000/mm3. platelets 7O,OOO/mmsand reticulocytes 16/100 red blood cells. The direct and indirect Coombs’ reaction was positive with IgG and IgM specificities, as well as with C3. Serum bilirubin was 2.3 mg/lOO ml, mostly of the unconjugated type. The diagnosis at that time was one of autoimmune hemolytic anemia associated with warm antibodies. Further investigation disclosed antibodies to DNA, circulating immune complexes and activation of the complement system (Table I), as well as a positive lupus erythematosus phenomenon. The serologic test for syphilis (VDRL) and the latex test were negative. Urine examination disclosed traces of protein (less than 0.5 g in 24 hours). Serum creatinine was 0.9 mg/lOO ml and creatininc clearance 110 ml/min. The patient was treated with large doses of prednisone (100 mg/day) and azathioprine (100 mg/day]. Her condition improved gradually, and she has continued to do well with maintenance therapy (15 mg of prednisone and 100 mg of azathioprine each, three times a week]. Over the full clinical course, she never presented clinical signs of SLE. In May 1975, a renal biopsy was performed. Case II. This 50 year old man has no relevant familial history. At the age of 13, he underwent splenectomy at Mount Sinai Hospital in New York for chronic idiopathic thrombocytopenic purpura which resulted in a normalization of the platelet count for two and a half years. He then suffered from recurrent bleeding from the gums and petechiae. The platelet count was less than lO,OOO/mm3 with little response to prednisone. In 1964, hc was given azathioprine (125 mg/day) in addition to prednisone (25 mg/day), and this produced a significant increase in platelets. When first examined by us in December 1973. the physical examination was unremarkable. Platelets were 106.000/mm3, the hematocrit value 44 per cent; the reticulocytes were 9/100 red blood cells and the direct Coombs’ test was positive with IgG specificity. Urine analysis showed no proteinuria and a normal sediment. Serum creatinine was 1.1 mg/lOO ml; crcatinine clearance 112 ml/min. As shown in Table I, antibodies to DNA, activation of the complement system, as well as a ccrculating anticoagulant to complex X, were found. VDRL and latex tests were negative. Despite a biology typical of SLE, the
92
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1979
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Journal of Medicine
patient never presented any clinical features of SLE. Presently, he is doing well on low doses of prednisone (15 mg three times a week] and azathioprine (150 mg, five times a week). A renal biopsy was performed in December 1975. Case III. This 35 year old man suffered from headaches from the age of 20. Thereafter, anemia developed. Autoimmune hemolytic anemia was diagnosed in Italy, with a hemoglobin level of 6.5 g/100 ml and a positive Coombs’ test. The patient was given cortisone for three years. With each recurrence of hemolytic anemia, he suffered from cephalea with no neurologic explanation of the headache. In 1967, splenectomy was performed which resulted in a marked, but only temporary, diminution of the anemia. He remained subicteric (1.6 to 2.2 mg/lOO ml of bilirubin). When he was first examined in February 1974, the physical examination confirmed a subicterus. Otherwise. the examination was unrevealing. At that time, the hemoglobin level was 9 g/100 ml, hematocrit value 31 per cent, and the number of reticulocytes was increased (7/100 erythrocytes). Direct and indirect Coombs’ test was positive with IgG and complement specificity. Urine analysis disclosed no abnormalities and serum creatinine was 1 mg/lOO ml. Table I gives the results of the immunologic investigations. Results of VDRL and latex tests were negative. The patient responded well to therapy with fluorocortolone (20 mg/day). A-mercaptopurine (50 mg/day] and colchicine (1 mg/day). Continued treatment proved necessary in order to prevent recurrence of overt hemolytic anemia. Renal biopsy was performed in April 1975. Case IV. A 36 year old man was seen for the first time in September 1974 with a known history of autoimmune hemolytic anemia. diagnosed in 1953. In the meantime, he was treated with ACTH. cortisone and blood transfusions. He refused splenectomy. The course of the disease with this therapy was characterized by several hemolytic crises accompanied by transitory enlargment of the spleen. Aseptic necrosis of both femur heads developed. When he first came to us, physical examination disclosed a mild enlargement of the spleen. His hemoglobin level was 11.2 g/100 ml, reticulocytes 34/100 erythrocytcs. platelets 114,000/mm3, direct and indirect Coombs’ reaction was positive with IgG and complement specificity. Antibodies to DNA were found as well as a circulating anticoagulant to complex X (Table I]. Results of the VDRL and latex tests were negative. Urine examination re-
Volume
66
AUTOIMMUNE
HEMATOLOGIC
DISEASES
AND
INFRACLINICAL
SLE-FAVRE
ET AL.
Figure 1. Case II. A representative glomerulus from the biopsy specimen of the patient. Except for a very mild increase of mesangial matrix, the glomerulus appears normal. Silver impregnation, magnification X 250. Figure 2.
Case IV. A representative glomerulus from the biopsy specimen of the patient. There is a slight enlargement of the mesangial area. Periodic acid-Schiff stain, magnification X
vcaled no abnormalities. Serum creatinine was
0.8 mg/lOO
ml
and creatinine clearance was 120 ml/min. The patient was azathioprine (125 then treated with prednisone (20 mg/day). mg/day] and colchicine (1 mg/day). Continued tredtmcnt proved necessary to control disease activity. A renal biopsy was performed
in 1974.
PATHOLOGIC
FINDINGS
Histology. The renal biopsy specimens are remarkably similar in Cases I. III and IV. Glomeruli show a very mild increase in mesangial matrix and mesangial cellularity, whereas the capillary walls appear normal (Figures 1 and 2). Tubules and blood vessels present no modification, and there are no interstitial infiltrates. The biopsy specimen in Case II also shows focal lesions: of 20 glomeruli, 3 are hyalinized; a fourth is partially sclerotic. Around these altered glomeruli, there are atrophic tubules and moderate inflammatory infiltrates. Electron Microscopy. The survey of glomcruli of the four patients confirms the low degree of alterations (Figure 3). Mesangial matrix is slightly increased and contains small, finely granular electron-dense deposits (Figure 4). Occasionally, the same deposits arc seen in the lamina densa of the basement membrane of capil-
lary loops. Segmental less electron-dense deposits occupy the lamina rara interna. Mesangial cells and podocytes are normal. In Cases II and IV, some nests of filamcntous inclusion bodies are observed in segmental widenings of endothelial cells [Figure 5). Immunofluorescence. Immunofluorescence of the specimens from the four patients shows granular staining of the capillary walls and within the mesangium for C3, Clq, IgG, and IgM. No tubular basement membrane staining is observed. COMMENTS The clinical problem of all these patients is one of an autoimmune blood disease: autoimmune hemolytic anemia in three patients and idiopathic thrombocytopenic purpura with an occasional positive Coombs’ test in one. Furthermore, the basic immunologic disorder is characterized by antinuclear antibodies, circulating anticoagulant in two patients and, on the kidney biopsy, very mild glomerulonephritis similar to lupus nephritis. Light microscopy, electron microscopy and immunohistology revaled features qualitatively comparable to the lesions seen in patients with SLE [5-81. On these grounds, one could consider including these
January 1979
The American Journal of Medicine
Volume 66
93
AUTOIMMUNE
HEMATOLOGIC
DISEASES
AND INFRACLINICAL
SLE-FAVRE
ET AL.
Figure 3. Case IV. Low power view of mesangial areas and capillary loops of a glomerulus. Only slight increase of the mesangial matrix is visible. Magnification X 6,000. Figure 4. Case II. Detail of a glomerulus in patient. Small finely granular electron dense deposits in mesangial matrix (arrow). Mesangial cell (M). Endothelial cytoplasm (E). Magnification X 15,000. Figure 5. Case IV. Detail of peripheral capillary loop of a glomerulus in patient. Nest of filamentous inclusions in endothelial cytoplasmic widening (arrow). Deposit in lamina rara interna of the basement membrane (D). Magnification X 25,000.
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four patients among the large number of patients exhibiting a very mild course of SLE [9]. However, in contrast to these patients with SLE, we are dealing with a very severe immunohematologic condition, with the patients requiring intensive treatment over a prolonged period of time, which contrasts with the clinical course and therapeutic requirements of patients presenting a very mild form of SLE. The long observation period also permits exclusion of the possibility that the severe immunohematologic condition represents only a transitory passage in the development of typical SLE. In the few patients whose initial disease manifestation is hemolytic anemia a typical picture of SLE usually develops, within less than a year [9,10]. The clinical picture in these patients more closely resembles the features of the natural history of the NZB mice as described by Howie and Simpson [4]. This strain of mice suffers from severe autoimmune hemolytic anemia, associated with antinuclear antibodies and, on histologic grounds, mild glomerulonephritis, without having the clinical picture of murine systemic lupus erythematosus. In this animal model, glomerulonephritis starts early in life, but remains latent over a very long period of time. A further similarity between the NZB autoimmune condition and the condition in these four patients is the self-perpetuating character of disease
DISEASES
AND INFRACLINICAL
SLE-FAVRE
ET AL.
and the male prevalence-3 to 1 in human subjects and 2 to 1 in the NZB mice. Although lymphoproliferative disorder develops in about 20 per cent of NZB mice, none of our patients had any evidence of such a development. However, the lymphoproliferative diathesis in mice may be a consequence of viruses present in abundance in these mice. Today, geneticists consider a polygenic basis to be responsible for the immunohemolytic anemia of NZB mice as well as for the murine SLE disease. Although such a polygenically rooted immunopathologic disorder becomes easily recognizable in an inbred species, it is extremely difficult to assess the immunogenetic background of a disease requiring three or more genes for its clinical manifestation in an outbred population. The fact that not only do we have the “human equivalent” of the NZB/NZW F1 hybrid SLE disease, but very probably also the human equivalent of the NZB-type of immune hemolytic anemia [ll], further supports the hypothesis that human SLE also has a polygenic immunogenetic basis. ACKNOWLEDGMENT We are grateful to Professor A. Cruchaud for performing the immunohistologic studies and to Mrs. 1. Ringrose for editorial assistance.
REFERENCES 1.
2. 3.
4.
5. 6.
7.
8.
Block SR, Win field lB, Lockshin MD, et al.: Studies of twins with systemic lup’us erythcmatosus. A review of the litcrature and nrcsentntion of 12 additional sets. Am I Med 59: 533.1975. Larson RA: Family studies in systemic lupus erythematosus ISLE). VII. Serum immunoglobulin IgG concentrations in relatives and spouses. J Chronic Dis 25: 205, 1972. Lambert PH. Dixon FJ: Gcncsis of antinuclear antibody in NZB/W mice, Role of gcnctic factors and of viral infection. Clin EXD Immunol6: 829.1970. Howic JB.‘Simpson LO: The immunopathology of NZB mice and their hvbrids. Textbook of Immunooatholow (Miescher PA, Mullcr-Ebcrhard HJ, cds], New York, Grunt & Stratton, Inc., 1976. p 247. Pollak VE, Pirani CL: Renal histologic findings in systemic lupus erythcmatosus. Mayo Clin Proc 44: 639.1969. Pincus T. Blacklow NR, Grimley PM, et al.: Glomcrular microtubules of systemic lupus erythematosus. Lancet 2: 1058. 1970. Morel-Maroger L, Met-y 1 Ph. Rich& G: LII~IISnephritis: immunofluorcsccncc studv of 54 cases. Glomcrulonephritis: Morphology, Natural History and Trcatmcnt. vol. 2, (Kincaid Smith P. Matthew TH, Becker LE, cds), New York, John Wiley&Sons, Inc., 1973, p 1183. Cruchaud A, Chcnais F, FourniE GJ, et al.: Immune complex deposits in systemic lupus crythcmatosus kidney without
9.
10.
12. 12.
13.
14.
15.
January 1979
histological or functional alteration. Em 1Clin Invest 5: 297. 1975. Micschcr PA, Paronctto F. Lambcrt PII: Systemic lupus er\thematosris. Textbook of Immunopatholngy (Miescher PA. Mullcr-Eberhard HJ. cds). New York, Griinc & Stratton, Inc., 1976, 11963. Estcs D, Christian CL: The natural historv of systemic lupus crythematosus by prospective analysis. hledicinn (Baltimore) 50: 85. 1971. Oken MM, Griffiths RW, Williams RC. et al.: Possible NZB svndrome in man. Arch Intern Med 132: 237, 1973. Izu~ S. Lambert PH. FnurniE GJ. et al.: Features of svstemic luuus crvthcmatosus in mice inicctetl with bacterial liuopo’lysaccharides. J Exp Med 145: 1115. 1977. Zublcr RH. Lange G, Lambcrt PH, et al.: Detection of immune complexes in ttnheated scra by modified ““I-t:lg binding test. Effect of heating on the hindiny of Clot bv immune complexes and appl&ation of the test to systemic Ir~pus crythcmatnsus. J Immunol 118: 232. 1976. Nydcggcr UE, Ackcrmann LA, Lambert Pfl. et al.: A simple automated method for complcmcnt estimation in a continuous flow svstcm. I Immunol ‘ItlO: 910. 1!172. Pcrrin LH, Lamhcrt PH. Nydcggcr IIE. et al.: Quantit.itinn of C3PA (factor B) and other complement components in diseases associated with A low C3 Icvcl. Clin Immtinol Immunopathol 2: 16, 1973.
The American Journal of Medicine
Volume 66
95
HERVB FAVRE. M.D. FRANCOIS CHATELANAT, M.D. PETER A. MIESCHER, M.D. Gtineva, Switzerlund
In four patients with a diagnosis of autoimmune hemolytic anemia or idiopathic thrombocytopenic purpura antinuclear antibodies and circulating immune complexes (Clq-BA test) have developed at some time in their history. Renal biopsy material was assayed with different methods. Immunofluorescence studies revealed granular deposits of immunoglobulin G (IgG), immunoglobulin M (IgM) and third component of complement (C3). Upon optic microscopy, three patients had mild mesangial proliferation, one a focal glomerulonephritis. Upon electron microscopy, all patients exhibited mesangial and/or subendothelial deposits. The patients have been followed for 18 to 37 years since the beginning of their disease. There has been no clinical evidence of systemic lupus erythematosus (SLE), although they present in their glomeruli immunologic and anatomic features compatible with this disease. These patients seem to be a human equivalent of the black NZB mouse which presents immunohematologic disorders and some biologic markers of SLE without having a full clinical picture of SLE. In human subjects, studies on twins [l], and findings of autoimmune markers in the families of patients with SLE [Z], provide evidence for genetic influences in the development of this disease. Furthermore, studies on NZB and NZW mice have contributed to the understanding of the genetics underlying the animal equivalent of human SLE, the NZB/NZW female hybrids showing a high incidence of murine SLE [3]. The incidence of autoimmune hemolvtic anemia with antinuclear antibodies and minimal kidney changesis high in NZB mice, but the full picture of SLE does not develop [4]. In this report we deal with four patients in whom clinical, biologic and immunologic data are similar to those observed in NZB mice. In view of the presence of circulating immune complexes and antibodies to DNA, kidney biopsies were performed in all patients iti order to immunochemically and ultrastructurally evaluate kidney pathology.
CASE REPORTS From the Departments of Medicine and Pathology, HBpital Cantonal. Geneva, Switzerland. This work has been supported by the Dinu-LiPatti Dubois-FcrriEre Foundation and the Montus Foundation. Requests for reprints should be addressed to Dr. H. Favrc, Division de Ncphrologic, HBpital Cantonal. 1211 Geneva 4 Switzerland. Manuscript accepted August 18. 1978.
Case I. The clinical history of this 63 year old woman began at the age of 48 when she complained of vaginal bleeding. The diagnosis of idiopathic thrombocytopenic purpura was made. Splenectomy was performed six months later without any change in the platelet count. She was seen for the first time by us in 1970. At that time, the physical examination was unrevealing. In summary, the laboratory findings showed a platelet count of 20,OOWmms. She was given prednisone and’Imuran@; with this medication, platelets returned to values around 100,0Wmms. In December 1974. she was hospitalized in
January 1979
The American Journal of Medicine
Volume 66
91
AUTOIMMUNE
TABLE I
HEMATOLOGIC
ET AL
Summary of Immunologic Laboratory Data Coombs’
Case No.
DISEASES AND INFRACLINICAL SLE-FAVRE
Sex
Test
F M M M
3+ 1+ 2+ 3+
I II Ill IV
Circulating
LE Ceils + -
ANF
(?,
•l+ + +
7 22 20 26
-
Normal values
a.7 f 3.1
C&O
Anticoagulant Clq-BA 67 33.2 31 44
+
13.7 f 5.6
-
20 14 16 36
+
7% 2.5
(%I 56 66 37 56 IOOf 25
Clq
(%I 120 100 98 72
77 100 90 40
IOOf 46
IOOf 32
36 72 36 20 IOOf 52
160 100 38 76 100f 36
NOTE: + = present, - = absent. ANF = The antinuclear factor was determined by immunofluorescence on human white blood cell nuclei. DS and S S = Double-stranded and single-stranded anti-DNA antibodies measured according to lzui et al. [ 121. Clq-BA = immune complexes were detected according to the method of Zubler et al. [ 131. CHso was estimated by the method described by Nydegger et al. [ 141, and the complement components Clq, C3, C4, B, by the method described by Perrin et al. [ 151.
emergency for fever and icterus which were found to be the consequence of a hemolytic crisis. The patient was pale and icteric. The remainder of the examination was within normal limits. On admission, the hematocrit value was 16 per cent, hemoglobin level 4.4 g/100 ml, red cells 1,300,000/mm3. platelets 7O,OOO/mmsand reticulocytes 16/100 red blood cells. The direct and indirect Coombs’ reaction was positive with IgG and IgM specificities, as well as with C3. Serum bilirubin was 2.3 mg/lOO ml, mostly of the unconjugated type. The diagnosis at that time was one of autoimmune hemolytic anemia associated with warm antibodies. Further investigation disclosed antibodies to DNA, circulating immune complexes and activation of the complement system (Table I), as well as a positive lupus erythematosus phenomenon. The serologic test for syphilis (VDRL) and the latex test were negative. Urine examination disclosed traces of protein (less than 0.5 g in 24 hours). Serum creatinine was 0.9 mg/lOO ml and creatininc clearance 110 ml/min. The patient was treated with large doses of prednisone (100 mg/day) and azathioprine (100 mg/day]. Her condition improved gradually, and she has continued to do well with maintenance therapy (15 mg of prednisone and 100 mg of azathioprine each, three times a week]. Over the full clinical course, she never presented clinical signs of SLE. In May 1975, a renal biopsy was performed. Case II. This 50 year old man has no relevant familial history. At the age of 13, he underwent splenectomy at Mount Sinai Hospital in New York for chronic idiopathic thrombocytopenic purpura which resulted in a normalization of the platelet count for two and a half years. He then suffered from recurrent bleeding from the gums and petechiae. The platelet count was less than lO,OOO/mm3 with little response to prednisone. In 1964, hc was given azathioprine (125 mg/day) in addition to prednisone (25 mg/day), and this produced a significant increase in platelets. When first examined by us in December 1973. the physical examination was unremarkable. Platelets were 106.000/mm3, the hematocrit value 44 per cent; the reticulocytes were 9/100 red blood cells and the direct Coombs’ test was positive with IgG specificity. Urine analysis showed no proteinuria and a normal sediment. Serum creatinine was 1.1 mg/lOO ml; crcatinine clearance 112 ml/min. As shown in Table I, antibodies to DNA, activation of the complement system, as well as a ccrculating anticoagulant to complex X, were found. VDRL and latex tests were negative. Despite a biology typical of SLE, the
92
January
1979
The American
Journal of Medicine
patient never presented any clinical features of SLE. Presently, he is doing well on low doses of prednisone (15 mg three times a week] and azathioprine (150 mg, five times a week). A renal biopsy was performed in December 1975. Case III. This 35 year old man suffered from headaches from the age of 20. Thereafter, anemia developed. Autoimmune hemolytic anemia was diagnosed in Italy, with a hemoglobin level of 6.5 g/100 ml and a positive Coombs’ test. The patient was given cortisone for three years. With each recurrence of hemolytic anemia, he suffered from cephalea with no neurologic explanation of the headache. In 1967, splenectomy was performed which resulted in a marked, but only temporary, diminution of the anemia. He remained subicteric (1.6 to 2.2 mg/lOO ml of bilirubin). When he was first examined in February 1974, the physical examination confirmed a subicterus. Otherwise. the examination was unrevealing. At that time, the hemoglobin level was 9 g/100 ml, hematocrit value 31 per cent, and the number of reticulocytes was increased (7/100 erythrocytes). Direct and indirect Coombs’ test was positive with IgG and complement specificity. Urine analysis disclosed no abnormalities and serum creatinine was 1 mg/lOO ml. Table I gives the results of the immunologic investigations. Results of VDRL and latex tests were negative. The patient responded well to therapy with fluorocortolone (20 mg/day). A-mercaptopurine (50 mg/day] and colchicine (1 mg/day). Continued treatment proved necessary in order to prevent recurrence of overt hemolytic anemia. Renal biopsy was performed in April 1975. Case IV. A 36 year old man was seen for the first time in September 1974 with a known history of autoimmune hemolytic anemia. diagnosed in 1953. In the meantime, he was treated with ACTH. cortisone and blood transfusions. He refused splenectomy. The course of the disease with this therapy was characterized by several hemolytic crises accompanied by transitory enlargment of the spleen. Aseptic necrosis of both femur heads developed. When he first came to us, physical examination disclosed a mild enlargement of the spleen. His hemoglobin level was 11.2 g/100 ml, reticulocytes 34/100 erythrocytcs. platelets 114,000/mm3, direct and indirect Coombs’ reaction was positive with IgG and complement specificity. Antibodies to DNA were found as well as a circulating anticoagulant to complex X (Table I]. Results of the VDRL and latex tests were negative. Urine examination re-
Volume
66
AUTOIMMUNE
HEMATOLOGIC
DISEASES
AND
INFRACLINICAL
SLE-FAVRE
ET AL.
Figure 1. Case II. A representative glomerulus from the biopsy specimen of the patient. Except for a very mild increase of mesangial matrix, the glomerulus appears normal. Silver impregnation, magnification X 250. Figure 2.
Case IV. A representative glomerulus from the biopsy specimen of the patient. There is a slight enlargement of the mesangial area. Periodic acid-Schiff stain, magnification X
vcaled no abnormalities. Serum creatinine was
0.8 mg/lOO
ml
and creatinine clearance was 120 ml/min. The patient was azathioprine (125 then treated with prednisone (20 mg/day). mg/day] and colchicine (1 mg/day). Continued tredtmcnt proved necessary to control disease activity. A renal biopsy was performed
in 1974.
PATHOLOGIC
FINDINGS
Histology. The renal biopsy specimens are remarkably similar in Cases I. III and IV. Glomeruli show a very mild increase in mesangial matrix and mesangial cellularity, whereas the capillary walls appear normal (Figures 1 and 2). Tubules and blood vessels present no modification, and there are no interstitial infiltrates. The biopsy specimen in Case II also shows focal lesions: of 20 glomeruli, 3 are hyalinized; a fourth is partially sclerotic. Around these altered glomeruli, there are atrophic tubules and moderate inflammatory infiltrates. Electron Microscopy. The survey of glomcruli of the four patients confirms the low degree of alterations (Figure 3). Mesangial matrix is slightly increased and contains small, finely granular electron-dense deposits (Figure 4). Occasionally, the same deposits arc seen in the lamina densa of the basement membrane of capil-
lary loops. Segmental less electron-dense deposits occupy the lamina rara interna. Mesangial cells and podocytes are normal. In Cases II and IV, some nests of filamcntous inclusion bodies are observed in segmental widenings of endothelial cells [Figure 5). Immunofluorescence. Immunofluorescence of the specimens from the four patients shows granular staining of the capillary walls and within the mesangium for C3, Clq, IgG, and IgM. No tubular basement membrane staining is observed. COMMENTS The clinical problem of all these patients is one of an autoimmune blood disease: autoimmune hemolytic anemia in three patients and idiopathic thrombocytopenic purpura with an occasional positive Coombs’ test in one. Furthermore, the basic immunologic disorder is characterized by antinuclear antibodies, circulating anticoagulant in two patients and, on the kidney biopsy, very mild glomerulonephritis similar to lupus nephritis. Light microscopy, electron microscopy and immunohistology revaled features qualitatively comparable to the lesions seen in patients with SLE [5-81. On these grounds, one could consider including these
January 1979
The American Journal of Medicine
Volume 66
93
AUTOIMMUNE
HEMATOLOGIC
DISEASES
AND INFRACLINICAL
SLE-FAVRE
ET AL.
Figure 3. Case IV. Low power view of mesangial areas and capillary loops of a glomerulus. Only slight increase of the mesangial matrix is visible. Magnification X 6,000. Figure 4. Case II. Detail of a glomerulus in patient. Small finely granular electron dense deposits in mesangial matrix (arrow). Mesangial cell (M). Endothelial cytoplasm (E). Magnification X 15,000. Figure 5. Case IV. Detail of peripheral capillary loop of a glomerulus in patient. Nest of filamentous inclusions in endothelial cytoplasmic widening (arrow). Deposit in lamina rara interna of the basement membrane (D). Magnification X 25,000.
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January 1979
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AUTOIMMUNE
HEMATOLOGIC
four patients among the large number of patients exhibiting a very mild course of SLE [9]. However, in contrast to these patients with SLE, we are dealing with a very severe immunohematologic condition, with the patients requiring intensive treatment over a prolonged period of time, which contrasts with the clinical course and therapeutic requirements of patients presenting a very mild form of SLE. The long observation period also permits exclusion of the possibility that the severe immunohematologic condition represents only a transitory passage in the development of typical SLE. In the few patients whose initial disease manifestation is hemolytic anemia a typical picture of SLE usually develops, within less than a year [9,10]. The clinical picture in these patients more closely resembles the features of the natural history of the NZB mice as described by Howie and Simpson [4]. This strain of mice suffers from severe autoimmune hemolytic anemia, associated with antinuclear antibodies and, on histologic grounds, mild glomerulonephritis, without having the clinical picture of murine systemic lupus erythematosus. In this animal model, glomerulonephritis starts early in life, but remains latent over a very long period of time. A further similarity between the NZB autoimmune condition and the condition in these four patients is the self-perpetuating character of disease
DISEASES
AND INFRACLINICAL
SLE-FAVRE
ET AL.
and the male prevalence-3 to 1 in human subjects and 2 to 1 in the NZB mice. Although lymphoproliferative disorder develops in about 20 per cent of NZB mice, none of our patients had any evidence of such a development. However, the lymphoproliferative diathesis in mice may be a consequence of viruses present in abundance in these mice. Today, geneticists consider a polygenic basis to be responsible for the immunohemolytic anemia of NZB mice as well as for the murine SLE disease. Although such a polygenically rooted immunopathologic disorder becomes easily recognizable in an inbred species, it is extremely difficult to assess the immunogenetic background of a disease requiring three or more genes for its clinical manifestation in an outbred population. The fact that not only do we have the “human equivalent” of the NZB/NZW F1 hybrid SLE disease, but very probably also the human equivalent of the NZB-type of immune hemolytic anemia [ll], further supports the hypothesis that human SLE also has a polygenic immunogenetic basis. ACKNOWLEDGMENT We are grateful to Professor A. Cruchaud for performing the immunohistologic studies and to Mrs. 1. Ringrose for editorial assistance.
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